Why is Doctor Credentialing so Important?

insurance claim formWhat is doctor credentialing and why is it so important? Well, credentialing is the process that insurance providers use to evaluate a physician’s history and their practice. The process involves doing a review of a doctor’s completed education, residential, training, and licenses. It also includes any certifications issued by a board in the doctor’s specialty.

The insurance providers complete this process before a doctor is allowed to join their network. Once the credentialing process is complete and the doctor is given the proper credentials, then he or she may receive reimbursement for treatment that they provide to the insurance company’s members.

From there, the insurance company may review credentials on a regular basis to ensure the doctor is fit to remain within the network. The standards in which this occurs relies on the state, regulatory bodies, and the accrediting organizations.

It is important to note that just because a doctor goes through the doctor credentialing process doesn’t mean that he or she will receive those credentials. Patients are also not guaranteed that they will receive a specific level of service from a doctor that is participating within the network. Credentialed doctors are independent and do not represent the insurance company in any way.

Why is the Credentialing Process Important to Patients?

The process of credentialing is one that most insurance providers are very thorough with. However, they are also efficient because they want their members to have access to doctors as quickly as possible after contracting with the insurance provider.

What to Expect from Doctor Credentialing

The process of credentialing is very detailed, which is why it can help to have a credentialing consultant working with you along the way. A credentialing consultant is able to help you throughout the process to ensure that it is carried out properly. This also removes a great deal of burden from your shoulders because you do not have to worry about whether or not you are missing anything while also having to deal with the logistics of running your practice.

So here is what you can expect from the process:

•    Provide information about your background and qualifications so that the information can be provided with the formal application. The insurance company will check this information to verify. They want to ensure that there is nothing negative and, if there is, what that issue was and if it was resolved. They utilize reliable sources to check the information against.
•    Your background will also be checked in any states where you are licensed. Even schools and hospital programs will be checked to ensure that your training is complete and that you have been accepted by the specialty board.
•    The DEA, the National Technical Information Service, and others are contacted to confirm that you are authorized to write prescriptions. Being able to write prescriptions is a very important part of credentialing so that the insurer’s members can receive the proper care.
•    Medicare and Medicaid are contacted to ensure that you are not banned from providing care to Medicare and Medicaid patients. This could have an impact on whether or not the insurance company decides to award credentials.
•    Your personal history is reviewed to see if there has ever been any disciplinary action, malpractice insurance coverage is confirmed, malpractice claims history is reviewed, hospital privileges are reviewed to see if they have been lost or limited, and employment background and work history is reviewed.

Provider name and office location is also gathered, as well as your gender, your specialties, the language you speak, the average age of your patient focus, hospital affiliation, medical group affiliation, and board certification.

This seems like a lot of information and that is because it is. However, it is necessary to ensure that physicians that are seeking credentialing are suitable according to the standards of the insurance company. While the process is largely the same among all insurance companies, there may be variations. This, once again, displays why a credentialing consultant can be quite beneficial during the process of credentialing. The insurance companies provide credentialing verification on tens of thousands of doctors every single year, so it is in everyone’s best interest to ensure that the application is filled out properly and that all supporting information is provided as requested.


It is ideal for a doctor to be credentialed with multiple insurance providers in order to have a solid patient base. If you need assistance completing the applications and providing the necessary information, MD Pro Solutions can help. To learn more, call us at 508-946-1665 or fill out our contact form and someone will call you.